Policy mh-new-models-care-kings-fund-may-2017

Authors
Chris Naylor
Holly Taggart
Anna Charles
May 2017
Mental health
and new models
of care
Lessons from the vanguards

Mental health and new models of care
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Contents
Key messages 3
Introduction 5
Aims and methodology 14
Scoping interviews 14
In-depth case study interviews 16
Stakeholder engagement 17
Nine principles for success 19
Mental health in new models of care:
examples from the vanguard sites 23
Highly complex needs 24
Long-term care needs 26
Urgent care needs 30
Whole-population health 31
Supporting infrastructure 33
Summary 35
Contents 1
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Contents2
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Emerging lessons for local system leaders 36
Incorporating mental health into integrated care teams 36
Broadening the scope of mental health 38
Focusing on prevention as well as care 38
Developing the workforce 39
Building the right relationships 40
Co-design and public involvement 41
Starting small and learning from experience 41
What next? 42
Progress so far 42
Barriers to be overcome 44
Opportunities ahead 45
Recommendations 51
Appendix A: Further resources 53
Appendix B: Case study site profiles 56
References 77
About the authors 82
Acknowledgements 83
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Key messages 3
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Key messages
•
• The new models of care introduced by the NHS five year forward view (Forward
View) create an important opportunity to deliver whole-person care that
responds to mental health, physical health and social needs together.
•
• Developing more integrated approaches to mental health should be a key
priority given the close links between mental health and physical health
outcomes, and the impact these have on the quality and costs of care. It is now
well established that when the mental health needs of people with physical
health conditions are not adequately addressed, this increases costs and
undermines patient outcomes.
•
• Many of the vanguard sites have included some mental health components
in their care models, with several reporting promising early results and some
emerging lessons that other areas may benefit from. For example, in areas
that have incorporated mental health expertise into integrated care teams,
team members report that the contribution of their mental health colleagues
has been highly valuable in improving the support delivered to people with
complex and ongoing care needs.
•
• Despite these positive steps, our overall assessment is that the full opportunities
to improve care through integrated approaches to mental health have not been
realised. The level of priority given to mental health in the development of new
models of care has not always been sufficiently high. This is not consistent with
the spirit of the commitment in The five year forward view for mental health
(Forward View for Mental Health), which identified integrating physical and
mental health as one of its three key priorities.
•
• The critical measure of success is that when taken together, the work done in
the vanguard sites allows adequate testing of hypotheses about the potential
impact of integrating mental health within new models of care. Our concern is
that the service changes brought about to date may not be sufficiently ambitious
to allow for this.

Key messages 4
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•
• In developing the multispecialty community provider (MCP) and primary and
acute care system (PACS) models further, there is significant scope to make
more progress in the following areas:
–
– ensuring that integrated care teams designed to support people with complex
and ongoing care needs can make full use of mental health expertise, with
mental health capacity and capabilities sufficient to meet the needs that exist
–
– making new forms of mental health support a core component of
enhanced models of primary care, so that primary care teams are better
equipped to address the wide range of mental health needs in general
practice, and to meet the physical health care needs of people with
long‑term mental health problems
–
– further strengthening mental health components of urgent and
emergency care pathways in accident and emergency (AE) departments
and elsewhere
–
– making public mental health and wellbeing central to population health
management approaches, including through a focus on perinatal
mental health, children and young people, where some of the greatest
opportunities for prevention lie.
•
• As new models of care are developed in other areas beyond the vanguard sites,
two things will need to be done to ensure that the opportunities relating to
mental health are not missed. First, testing the mental health components of
existing vanguard sites must be a central part of local and national evaluations
of new care models. Second, other local areas rolling out MCPs, PACS and
related care models should aim to go further than the vanguard sites in the four
areas listed above.
•
• Sustainability and transformation plans (STPs) are the main mechanism for
delivering the Forward View. It is essential that all STPs set out ambitious but
credible plans for improving mental health and integrating mental health into
new models of care.
•
• In Next steps on the NHS five year forward view NHS England (2017) sets an
ambition to ‘make the biggest national move to integrated care of any major
western country’. Progress in developing integrated approaches to mental
health care must be an essential success criterion for achieving this ambition.
While the commitment to parity of esteem between mental and physical health
is hugely significant, it is time to turn the rhetoric into reality.

Introduction5
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1 Introduction
Mental health care is often disconnected from the wider health and social care
system – institutionally, professionally, clinically and culturally. Artificial boundaries
between services mean that many people do not receive co-ordinated support for
their physical health, mental health and wider social needs, and instead receive
fragmented care that treats different aspects of their health and wellbeing in
isolation. Figure 1 illustrates some of the groups of people who frequently suffer
as a result.
Figure 1 Potential beneficiaries of integrated approaches to mental health
Who could benefit
from integrated
mental health care?
People with severe mental health
problems who often experience
poor physical health and less
effective care and support for
their physical health needs
People with long-term physical
health conditions who would
benefit from support for the
psychological aspects of adjusting
to and living with their condition
People with multiple physical
and mental health conditions,
including older people with
frailty as well as younger people
with highly complex needs
People with persistent physical
symptoms such as chronic pain that
can be maintained and reinforced
by psychological and biological
processes acting in tandem

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Previous research has argued that integrated care initiatives in England and
elsewhere have not yet focused enough on the opportunities to overcome these
boundaries and develop more integrated approaches towards mental health (Naylor
et al 2016). This is despite evidence indicating that there is significant scope both
to improve the quality of care and to use available resources more efficiently by
doing so. For example, it is now well established that mental health problems are
very common among people with long-term physical health conditions, and that
when these mental health needs are not adequately addressed, the effect is often to
drive up the costs of care and undermine outcomes (Naylor et al 2012). In the case of
people with severe mental illnesses, poor physical health and barriers to accessing
physical health care have led to a situation where they are likely to die 10 to
20 years earlier (on average) than the wider population – one of the starkest health
inequalities seen in the UK (Working Group for Improving the Physical Health of People
with SMI 2016).
Figure 2 (p 7) provides a summary of key facts and figures illustrating the case for
change in terms of patient outcomes, system pressures and the financial costs of the
current situation, while Figure 3 (p 8) illustrates some of the mechanisms through
which physical and mental health interact.

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Figure 2 The case for developing integrated approaches to mental health:
summary of key facts and figures
Patient outcomes
System pressures
Financial costs
• Co-morbid mental health problems raise total health care costs by
at least 45 per cent for each person with a long-term condition
and co-morbid mental health problem (Naylor et al 2012).
• Between 12 per cent and 18 per cent of all NHS expenditure
on long-term conditions is linked to poor mental health and
wellbeing – between £8 billion and £13 billion in England each
year (Naylor et al 2012).
• Persistent physical symptoms are estimated to cost the NHS
around £3 billion each year (Bermingham et al 2010).
• The lifetime effects of perinatal mental health problems cost the
NHS an estimated £1.2 billion for each annual cohort of births
(Bauer et al 2014).
• People with mental health problems use significantly more
unplanned hospital care for physical health needs than the
general population, including 3.6 times the rate of potentially
avoidable emergency admissions for ambulatory care sensitive
conditions (Dorning et al 2015).
• Inadequate treatment of mental health problems among
general hospital inpatients has been linked to higher rates of
re‑attendance at AE after discharge (Joint Commissioning
Panel for Mental Health 2013).
• Poor management of persistent physical symptoms adds to
pressures in primary care, with these symptoms being present in
up to 30 per cent of all GP consultations (Kirmayer et al 2004).
• Dementia, depression and other mental health problems can
make providing services for older people with multiple health
problems significantly more complex.
• Poor mental health is a major risk factor for a wide range of
physical health conditions, and can also be a consequence of
physical illness. Around 30 per cent of people with one or more
long-term physical health conditions also have a mental health
problem; this figure is higher among people with multiple
conditions (Naylor et al 2012).
• Depression and anxiety disorders lead to significantly poorer
outcomes among people with diabetes, cardiovascular disease,
chronic obstructive pulmonary disease (COPD) and other
long-term conditions (Jünger et al 2005; Katon et al 2005;
Blumenthal et al 2003; Lespérance et al 2002).
• Compared to the general population, people with severe mental
illnesses are 4.7 times more likely to die from liver disease,
4.6 times more likely to die from respiratory disease, 3.2 times
more likely to die from cardiovascular disease, 1.7 times more
likely to die from cancer, and overall die 10–20 years earlier on
average (Taggart and Bailey 2015; Brown et al 2010).

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Figure 3 Mechanisms through which physical and mental health interact
Source: Naylor et al 2016
• Physical health side effects
of psychotropic medication,
eg, raised risk of obesity
• Direct effects of chronic stress on
the cardiovascular, nervous and
immune systems
• Direct effects of eating disorders or
self-harm, eg, electrolyte imbalances
• Higher rates of unhealthy behaviours,
eg, smoking or excessive alcohol use
• Reduced ability or motivation to
manage physical health conditions
• Less effective help-seeking
• Barriers to accessing physical
health care, eg, as a consequence of
stigma or ‘diagnostic overshadowing’
Social determinants
eg, poverty, social isolation, discrimination,
abuse, neglect, trauma, drug dependencies
Mental health
• Mental health impact of
living with a chronic
condition
• Psychiatric side effects of
medication, eg, steroids
• Direct effects of hormonal
imbalances on mental health
• Increased risk of
dementia among people
with diabetes/
cardiovascular disease
Physical health

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The new models of care introduced by the Forward View represent the most
ambitious attempt yet to dissolve traditional boundaries in the NHS, in particular
by bringing together fragmented budgets and services into coherent local systems
of care (NHS England et al 2014). These innovations create an important opportunity
to deliver whole-person care that responds to people’s mental and physical health
needs together.
The traditional divide between primary care, community services, and hospitals
– largely unaltered since the birth of the NHS – is increasingly a barrier to the
personalised and coordinated health services patients need. And just as GPs and
hospitals tend to be rigidly demarcated, so too are social care and mental health
services even though people increasingly need all three. Over the next five years and
beyond the NHS will increasingly need to dissolve these traditional boundaries.
To put this vision into practice, a number of new care models are being developed
and tested in 50 vanguard sites across England, supported by an investment of more
than £330 million over three years (ending in 2017/18). These care models create a
new platform to support integrated working, including in relation to mental health.
Particularly relevant to the goal of developing integrated care are the MCP and
PACS models, as well as the related primary care home model (see box, p 10). The
policy ambition is that most of the population will be covered by a PACS or MCP
model or similar within the next few years. These models will be rolled out beyond
the vanguard sites through the 44 STPs that have been developed across England
(NHS England 2016f).

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New care models in the vanguard sites and beyond
In the vanguard sites
•
• Multispecialty community providers (MCPs). GP practices in a local area are grouped
into a number of neighbourhood clusters, each covering a population of 30,000 to
50,000. In each neighbourhood, a multidisciplinary team is established to allow GPs
to work together with other health and social care professionals to provide more
integrated services outside of hospitals. These teams might include some specialists
currently working in acute hospitals, as well as nurses, mental health professionals,
community health services and social workers.
•
• Primary and acute care systems (PACS). A single entity or group of providers takes
responsibility for delivering a full range of primary, community, mental health and
hospital services for their local population, to improve co-ordination of services and
move care out of hospital where appropriate. The PACS model is fundamentally
similar to the MCP model but is wider in scope (potentially including a greater range
of hospital services) and may also be bigger in scale as a result.
•
• Urgent and emergency care models. These focus on improving the co‑ordination
of urgent and emergency care services and reducing pressure on AE departments.
Changes include the development of hospital networks, new partnership options for
smaller hospitals and greater use of pharmacists and out-of-hours GP services. In
2017, in addition to their existing remit, sites implementing urgent and emergency
care models were selected to test new models of mental health crisis care for children
and young people, supported by an additional investment of £4.4 million.
•
• Acute care collaboration models. These involve linking hospitals together to improve
their clinical and financial viability, reducing variation in care and improving efficiency.
Several of the ACC vanguards are focused on developing networked approaches
towards a specific clinical area such as cancer, orthopaedics or neurology. There is
one ACC vanguard focused on mental health – the MERIT vanguard (see ‘Aims and
methodology’ section, p 17).
•
• Enhanced health in care homes models. These involve NHS services working in
partnership with care home providers and local authority services to develop new
forms of support for older people.
continued on next page

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The need to develop more integrated approaches to mental health was reinforced
by the Forward View for Mental Health, which placed significant emphasis on
integration as part of a national strategy for improving mental health (Mental
Health Taskforce 2016) (see box, p 12). In response to this, NHS England announced
plans to invest in various forms of integrated support, including through mental
health liaison services in acute hospitals, integrated perinatal mental health care,
psychological therapy services for people with long-term conditions, and improved
access to physical health assessment and follow-up for people with severe mental
health illnesses (NHS England 2016b). The focus on integration was also included
in guidance to STP leaders, which stated that their plans should include work on
‘supporting physical and mental health needs in every interaction’ across the whole
system, including through new models of care (NHS England 2016e).
Parallel to these developments, new opportunities to incorporate mental health
in work on integrated care have also been identified in other countries. The rise
of accountable care organisations (ACOs) in the United States has created similar
opportunities to address mental health, physical health and other needs as part of
New care models in the vanguard sites and beyond continued
Beyond the vanguards programme
•
• Primary care homes. Scaled-up primary care based on multidisciplinary teams serving
populations of 30,000 to 50,000. These units also form the basic building blocks of
MCP and PACS models, but the primary care home model is often smaller in scale and
potentially involves less structural or contractual change. Primary care homes are not
formally part of the vanguards programme but are closely related, and are currently
being tested in 15 pilot sites across England as part of a programme led by the
National Association of Primary Care and the NHS Confederation.
•
• New care models in tertiary mental health services. Six sites across England are
trialling a new model of care that enables secondary providers of mental health
services to manage care budgets for tertiary mental health services (for example,
secure services or specialised services for children and young people). The aim is to
improve outcomes and reduce the need for out-of-area placements.

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the same care pathways. These reforms are intended to provide greater flexibility
in terms of how resources are allocated and how different staff groups are used.
A number of authors have argued that many of the first waves of ACOs have
missed the opportunity to make mental health a central part of their work from
the outset, and that there is a lack of adequate policy incentives for them to do so
(Kathol et al 2015; Lewis et al 2014, p 20; O’Donnell et al 2013). As new models of
care are adopted across increasingly large parts of the English NHS, it is important
to ensure that we learn from these missed opportunities and do not repeat them.
This is particularly pertinent given the intention to develop accountable care
systems (seen as a step towards the ACO model) in a number of areas of the
country, with NHS England and NHS Improvement providing support to local
systems moving towards this approach (NHS England 2017).
Forward View for Mental Health
The Mental Health Taskforce, set up by NHS England in March 2015, was tasked with
developing a five-year, all-age national strategy for mental health in England to 2020,
aligned to the Forward View. Its final report, The five year forward view for mental health,
published in February 2016, marked the first time that a shared national ambition for
mental health had been set for the arm’s length bodies of the NHS, supported by a pledge
to invest an additional £1 billion per year by 2020/21.
The report made 58 recommendations on: prevention; improving the quality and
accessibility of care; innovation and research; workforce; data and transparency; incentives,
levers and payment; and regulation and inspection. The taskforce also recommended a
series of access and waiting time standards to be achieved by 2021. Specific commitments
include the following.
•
• 30,000 more women each year will have access to evidence-based specialist mental
health care during the perinatal period.
•
• 70,000 more children and young people will be able to access high-quality mental
health care when they need it.
•
• An additional 600,000 adults with anxiety and depression will have access to integrated
evidence-based psychological therapies, resulting in at least 350,000 people
completing treatment.

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Forward View for Mental Health continued
•
• 60 per cent of people experiencing a first episode of psychosis will be treated with a
care package approved by the National Institute for Health and Care Excellence (NICE)
within two weeks of referral.
•
• 280,000 more people living with severe mental illnesses will have their physical
health needs met each year through early detection and by expanding access to
evidence-based care.
•
• An additional 29,000 people per year living with mental health problems will be
supported to find work or stay in work through increasing access to psychological
therapies for common mental health problems and doubling the reach of employment
support using the Individual Placement and Support (IPS) model.
•
• Crisis resolution and home treatment teams will deliver 24/7 care and at least half of
all acute trusts will deliver ‘core 24’ liaison psychiatry.
The Forward View for Mental Health and the subsequent implementation plan (NHS
England 2016b) included a significant focus on integrated approaches to mental health,
including ambitions to expand access to psychological therapies in primary care for people
with long-term conditions, to strengthen liaison mental health services in general acute
hospitals, and to develop integrated perinatal mental health services.

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2 Aims and methodology
This report explores what an integrated response to mental health in the context
of new models of care could look like. It is based on research conducted jointly by
The King’s Fund and the Royal College of Psychiatrists. Our research focused on a
number of issues, including:
•
• how vanguard sites are developing integrated approaches to mental health
•
• the relative level of priority being placed on this
•
• lessons that are applicable to other parts of the country adopting new
models of care
•
• the impact of changes made so far.
The research was based on the following methodological components:
•
• scoping interviews with leaders from 22 vanguard sites
•
• in-depth stakeholder interviews in a sub-set of three selected vanguard sites
•
• an expert workshop and roundtable event
•
• insights from the Vanguard Expert Reference Group at the Royal College
of Psychiatrists.
Scoping interviews
We contacted leaders in all 50 vanguard sites to ask for information on the mental
health components of their work. Scoping interviews were then conducted
with leaders from 22 sites between December 2015 and October 2016, either by
telephone or through a site visit. In January 2017, we also conducted a survey
of project managers leading the vanguard sites to gather further evidence of
progress made in relation to mental health. In total, we collected information
from 29 vanguard sites, listed below.

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MCP vanguards
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• All Together Better Sunderland
•
• Better Local Care (Southern Hampshire)
•
• Dudley Multispecialty Community Provider
•
• Rushcliffe Multispecialty Community Provider
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• The Connected Care Partnership (Sandwell and West Birmingham)
•
• Tower Hamlets Together
•
• Wellbeing Erewash
•
• West Cheshire Way
•
• West Wakefield Health and Wellbeing Ltd
PACS vanguards
•
• Harrogate and Rural District
•
• My Life a Full Life (Isle of Wight)
•
• North East Hampshire and Farnham
•
• Northumberland Accountable Care Organisation
•
• Salford Together
•
• South Somerset Symphony Programme
•
• Wirral Partners
Urgent and emergency care vanguards
•
• Cambridge and Peterborough
•
• Greater Nottingham System Resilience Group
•
• Leicester, Leicestershire and Rutland System Resilience Group
•
• North East Urgent Care Network
•
• Solihull Together for Better Lives

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Acute care collaboration vanguards
•
• Developing One NHS in Dorset
•
• Foundation Healthcare Group (Dartford and Gravesham)
•
• Mental Health Alliance for Excellence, Resilience, Innovation and Training
(MERIT) (West Midlands)
•
• Moorfields
•
• The Neuro Network (The Walton Centre, Liverpool)
Enhanced health in care homes vanguards
•
• Airedale and Partners
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• East and North Hertfordshire Clinical Commissioning Group
•
• Gateshead Care Home Project
In-depth case study interviews
On the basis of our scoping work, we selected three case study sites where initial
discussions indicated that there was a relatively substantial focus on mental health
integration as part of the vanguard work. These were:
•
• North East Hampshire and Farnham PACS vanguard
•
• Tower Hamlets Together MCP vanguard
•
• West Cheshire Way MCP vanguard.
A profile of each is provided in Appendix B.
In these three sites, we conducted a total of 20 qualitative interviews with a range of
stakeholders between September and November 2016. We interviewed clinical and
managerial staff, including frontline clinicians as well as individuals in strategic roles.
The interviews included mental health and non-mental health staff.
We chose to focus our in-depth research on MCPs and PACS because the emphasis in
these care models on dissolving traditional boundaries between hospital, community,

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primary, social and mental health care fits most closely with our focus on integrated
approaches to mental health. However, in the report, we also draw on material
collected through our scoping interviews to describe relevant developments in other
vanguard types, including in the urgent and emergency care vanguards, most of
which have included a focus on improving mental health crisis care.
There is one vanguard in England (an ACC vanguard) that is specifically focused
on mental health – MERIT. Through a partnership of four mental health providers
serving a combined population of more than 3 million people, this alliance aims to
improve acute mental health services by sharing best practice and developing new
ways of working that are more effective, efficient and consistent. The vanguard is
focusing on areas including co-ordinated emergency response, improved discharge
from inpatient care and more support for recovery and relapse prevention in the
community. In this report, we describe elements of the MERIT programme that
relate most closely to the main themes addressed in our research, particularly those
around integrated care and the relationship between mental health services and the
wider system.
We did not conduct in-depth research on the ‘enhanced health in care homes’
vanguards, but acknowledge that many of these sites are conducting work intended
to improve the way people with dementia are supported in care homes.
Stakeholder engagement
In August 2016 we held an engagement workshop involving service users and
carers, a range of mental health professionals, other health and care professionals
(including GPs), senior managers from provider organisations, commissioners
and other stakeholders. This workshop explored what good practice might look
like – including from a service user and carer perspective – and underpins the nine
principles for success described in the next section.
In November 2016 a roundtable event was held at the Royal College of Psychiatrists
focusing on the mental health components of urgent and emergency care vanguards.
The event was attended by leaders of some of those vanguard sites, and provided a
way of gathering further intelligence and testing emerging findings.

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Our work was also informed by the Vanguard Expert Reference Group at the Royal
College of Psychiatrists, which includes representation from the College’s faculties
and divisions, specialist advisers and college leads as well as from service users
and carers, the Academy of Medical Royal Colleges, the Royal College of General
Practitioners and the National Collaborating Centre for Mental Health.
Further to this, in January 2017 we contacted clinical associates working in the new
care models team at NHS England, as well as mental health leads in strategic clinical
networks across England, in order to gather further information about mental
health plans across the vanguard programme.

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3 Nine principles
for success
We wanted to start with an understanding of what, in principle, successful
integration of mental health within new models of care would look like. The
engagement workshop with frontline staff, service users, carers, providers,
commissioners and relevant national stakeholders (held in August 2016) aimed
to identify design principles to guide the development of integrated approaches
to mental health through new models of care.
Drawing on the views and experiences of workshop participants, we identified nine
key principles for successful integration of mental health in new models of care.
Local system leaders can use these principles to help ensure that integration of
mental health is a core part of the development of new care models, and to capitalise
on the opportunities this presents.
1. The commissioning, design and implementation of new models of care should
be consistent with the requirement to deliver parity of esteem.
The requirement to deliver parity of esteem, defined as ‘valuing mental health
equally with physical health’, has been laid out in legislation and numerous policy
documents over recent years. It is characterised by: equal access to the most effective
and safest care and treatment; equal efforts to improve the quality of care; the
allocation of time, effort and resources on a basis commensurate with need; equal
status within health care education and practice; equally high aspirations for service
users; and equal status in the measurement of health outcomes (Royal College of
Psychiatrists 2013). These principles must be reflected throughout the development
of new models of care.

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2. Mental health should be considered from the initial design stages of new models
of care.
The fundamental changes needed are likely to be harder to achieve if mental health
is added onto pre-existing plans that have not considered it from their inception. To
achieve meaningful integration of mental health in new care models, it must be a
key consideration throughout the entire development process, including during the
early design phases.
3. New care models should address and measure outcomes that are important
to patients and service users, identified through a process of co-design.
It is important that new models of care address outcomes that are important
to service users and carers, in addition to outcomes designed to bolster the
financial sustainability of the system. Co-designing the care model with people
using services and the wider local population is an essential part of this.
Meaningful public engagement is necessary to identify the outcomes that are most
important to the population being served, and the design of new care models
should then follow from these priorities. Once the care model is implemented,
progress against these outcomes should be measured systematically and include
patient‑reported measures.
4. New care models should take a whole-person approach spanning an individual’s
physical, mental and social needs.
New models of care should focus on delivering whole-person care that supports
mental health alongside other aspects of health, rather than being addressed in
isolation. This requires attention to the full range of an individual’s needs, including
their psychological and social needs – regardless of whether their primary health
need is mental or physical in nature. As part of this, there needs to be a clear
understanding among those involved in developing new models of care that mental
health is about more than mental illness; good mental health is a key determinant of
other outcomes and should be considered as a routine part of care.

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5. New models of care should extend beyond NHS services to include all organisations
that may impact on people’s health and wellbeing.
Relationships and networks should be built with a variety of partners, not only those
delivering NHS-funded services. Key partners include social care, housing and
voluntary sector organisations as well as employers and the education system, all of
which can play an indispensable role in relation to mental health. Through bringing
together parts of the wider system, new models of care can capitalise on the full
range of assets in an area.
6. Invest in building relationships and networks between mental and physical health
care professionals.
New care models should be designed in a way that helps to break down the barriers
between organisations and individuals. This will require an explicit focus on
strengthening relationships at all levels, including between senior leaders from
different organisations as well as between frontline staff from different professions
and provider organisations.
7. New models of care should enhance the provision of upstream, preventive
interventions to improve mental health and wellbeing.
Strengthening prevention should be a key focus for new care models, including
primary, secondary and tertiary prevention. For example, integrated care teams
established as part of new care models should aim to address the range of factors
(including social and environmental factors) that shape the mental and physical
health and wellbeing of the people they are serving.
8. Every clinical interaction should be seen as an opportunity to promote mental
and physical wellbeing.
All interactions between health care professionals and members of the public
represent valuable opportunities to help people improve their mental and physical
wellbeing. Staff should be equipped with the necessary knowledge, information
and skills to initiate conversations with people about their mental wellbeing, to
encourage positive behaviour change, and to signpost to local support resources.

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9. All frontline staff should receive appropriate training in mental health, regardless
of the setting in which they work.
Training should equip staff to recognise and manage common mental health
problems at different stages in the life course, and to understand the psychological
components of physical illness. Where appropriate, education and training should
be conducted on an inter-professional basis, bringing together staff working in
physical and mental health care settings to share their knowledge and expertise.
These nine principles provide an overview of the approach to mental health
integration that key stakeholder groups would like to see implemented through new
models of care. In the next section, we explore the approaches being taken to mental
health integration in a number of vanguard sites, providing insights into how some
of these principles may be applied in practice.

Mental health in new models of care: examples from the vanguard sites 23
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4 Mental health in new
models of care: examples
from the vanguard sites
This section describes examples of how mental health is being incorporated into
new models of care, primarily drawing on our research in two MCP vanguards and
one PACS vanguard (see Aims and methodology section, p 16). Where relevant, we
also include intelligence gathered from other vanguard sites, including some of the
urgent and emergency care vanguards.
This section has been structured according to the framework that MCPs and PACS
are expected to operate within (NHS England 2016c, 2016g). The framework describes
how successful MCP and PACS models involve making changes at four levels, as
shown in Figure 4.
Figure 4 The four levels of the MCP and PACS care models
Source: Adapted from NHS England 2016c, 2016g
Proportion of the population
Highly complex needs
Whole-population health
Urgent care needs
Long-term
care needs

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The section concludes by describing the supporting infrastructure that has been
developed to enable changes at each of these levels. Our intention is not to provide
a comprehensive stocktake of all relevant developments, but rather to illustrate the
range of work being done on mental health in vanguard sites, and to highlight some
of the most common components.
Highly complex needs
A major focus of work on new models of care has been the development of improved
support in the community for people with highly complex care needs. This often
includes older people with frailty, people with multiple long-term conditions
and high social care needs, and people receiving end-of-life care. Services being
developed for these groups are typically targeted at a small fraction (2–5 per cent)
of the population who use health and social care services most frequently.
The main approach seen in the vanguard sites and elsewhere to improve care for
people with highly complex needs is the development of integrated care teams
covering a local area or ‘neighbourhood’.
Neighbourhood or locality-based integrated care teams form the mainstay of
MCP and PACS models, and are also the basis of the primary care home model.
These multidisciplinary teams typically cover populations of 30,000 to 50,000, and
bring together a range of community health and social care professionals working
alongside a cluster of GP practices. In most MCPs and PACS there is some form of
mental health input into these teams, but arrangements vary considerably. Some
sites have chosen to fully embed mental health professionals into integrated care
teams, whereas others have arrangements in place for consultation and liaison with
staff in separate mental health teams.
Many integrated care teams focus primarily (although often not exclusively) on older
people. As such, there has been a particular emphasis on securing expertise in relation
to older people’s mental health. This includes advice about dementia management as
well as other conditions common among older people, such as depression.
In North East Hampshire and Farnham PACS, mental health expertise is directly
embedded in locality integrated care teams. There are currently 2.3 full-time
equivalent (FTE) mental health professionals (two nurses and one occupational

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therapist) working across five integrated care teams. These individuals are involved
in discussion of all cases at weekly referral meetings and multidisciplinary team
meetings, and carry their own caseload. Their primary focus is on older adults with
co-morbid physical and mental health conditions, but the intention is that the client
group served will widen as the care model develops. They receive monthly clinical
supervision from a consultant psychiatrist, who they can also contact for specific
advice (eg, in relation to medications).
Similar arrangements have been developed in Harrogate and Rural District PACS,
where each community care team includes a mental health practitioner working
alongside two district nurses, two physiotherapists, two occupational therapists, a
pharmacist and a social care assessor.
In Tower Hamlets Together MCP, a senior community mental health nurse is
included in each integrated community health team. Linked with GP practices,
these teams provide co-ordinated health and social support to all patients over the
age of 18 identified as having complex needs. This includes anybody on the primary
care registers for dementia, palliative care or living in a care home, as well as people
who have been identified by their clinician as needing a multidisciplinary approach.
The mental health nurses are supported by a half-time consultant psychiatrist
working specifically as part of the integrated care programme. The nurses attend
practice-based multidisciplinary team meetings to help identify patients who
potentially have a mental health problem that may be exacerbating their physical
illness. They also provide brief support and treatment to patients requiring
additional input, along with consultation and training to community health teams
and primary care professionals. The teams also support care homes in the borough
to deliver person-centred care for people with dementia.
West Cheshire Way MCP is using a different model, involving link worker
arrangements designed to enable the integrated care teams to work in liaison with
mental health professionals. Two main sources of support are available. First, for
older adults, each locality is supported by a designated mental health nurse in the
local older people’s mental health team. Members of the integrated care team can
contact their named clinical lead by phone for advice, and the lead may be invited
to participate in a case discussion in a multidisciplinary team meeting. Second,
for working-age adults, each of the integrated care teams has a link worker in the
primary care mental health service (see below).

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A related approach used in some vanguard sites is the ‘extensive care’ model,
developed for supporting people with the very highest levels of care needs. The
model involves an ‘extensivist’ (usually a community geriatrician or GP) assuming
overall clinical responsibility for a person’s care from their general practice. The
extensivist works alongside a multidisciplinary team to address all aspects of a
person’s care in a co-ordinated way. As part of the Fylde Coast MCP an extensive
care service has been developed in Blackpool aimed specifically at people with
complex mental health needs, substance abuse and/or social problems.
Long-term care needs
A central concern of work on new models of care has been to improve care for
people with long-term conditions and other ongoing care needs. These services are
typically targeted at the 20 per cent of the population who use health and social care
services most frequently (ie, a broader group than those with highly complex needs,
focused on in the previous section).
The aim is to provide a broader range of services in the community that integrate
primary, community, social and acute care services, and bring together physical
and mental health. In addition to the integrated care teams described earlier (which
often focus on both complex and long-term care needs), other approaches being
implemented include enhanced mental health provision in primary care, social
prescribing, and programmes to support personal recovery.
Enhancing mental health provision in primary care
A number of vanguards are enhancing the mental health support and expertise
available in primary care. For example, one component of the West Cheshire Way
MCP has involved strengthening the local primary care mental health service. This
service is delivered primarily by community psychiatric nurses, nurse therapists and
psychologists. As part of the vanguard programme a consultant liaison psychiatrist
has been added to the team, who splits their time between the primary care and
acute hospital liaison services. This has enhanced the service’s ability to support
people with co-morbid physical and mental health problems, chronic pain and other
persistent physical symptoms. The vanguard work has also involved setting up a
link worker arrangement with local integrated care teams, as described earlier in
this section.

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Tower Hamlets Together MCP, working with partners in neighbouring boroughs, has
developed a primary care mental health service supporting the discharge of people
with stable serious mental illness to primary care, and providing step-up support to
people from primary care. The service includes a contract with practices to provide
additional support for service users with a focus on healthy lifestyles, along with a
team of primary care-based mental health professionals. The model is reported to
have brought about a significant improvement in communication between secondary
and primary care, with regular practice-based multidisciplinary team meetings
attended by consultant psychiatrists.
North East Hampshire and Farnham PACS is expanding its improving access to
psychological therapies (IAPT) programme as part of the national policy drive to
extend the scope of these services and to integrate them more closely with primary
care. The area is one of 22 ‘early implementer’ sites being supported to lead the way in
integrating IAPT services with physical health care. The care pathways being focused
on include those for persistent physical symptoms and for COPD. This does not fall
directly under the vanguard, but is viewed locally as being part of the same drive to
bring mental and physical health pathways together.
As part of its vanguard programme, Rushcliffe MCP in Nottinghamshire has
developed a primary care psychological medicine service. This focuses on supporting
people with persistent physical symptoms and others who frequently attend primary
care, and is delivered by experienced liaison nurses and a liaison psychiatrist who
also works in the local acute trust. Common input includes: case management;
diagnosis of mixed medical and psychiatric morbidity; training, supervision and
support for GPs and other professionals; and educating patients.
Accessing community resources
There has been a growing interest across the country in the use of social prescribing
and related approaches to connect people with resources in their local community
aimed at improving health and wellbeing, with some evaluations reporting positive
results in terms of patient outcomes and service use (Dayson et al 2013; Kimberlee
2013). Social prescribing allows health care professionals to refer people to a range
of non-clinical services to address their needs in a holistic way, and often focuses
on improving mental health and wellbeing. Vanguard sites have developed various
approaches towards supporting people to access these kinds of resources.

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In North East Hampshire and Farnham PACS, the Making Connections programme
includes Making Connections workers (a new role delivered through the voluntary
sector) based in general practices. These individuals act as navigators and can
connect people to local resources as well as helping them to identify and access
voluntary services in the community that may improve their health and wellbeing.
This enhances the non-clinical support available to patients and service users, and
provides GPs and professionals in the integrated care teams with an additional type
of support to offer.
West Cheshire Way MCP has introduced a similar role – that of wellbeing
co‑ordinators – in each integrated care team. These staff are reported to play a
critical role in promoting positive mental health and wellbeing among the people
supported by the team. Their main role is to help connect people with local
voluntary and community sector services – particularly people who are at risk of
social isolation and are in need of some extra support, or who are known to be
experiencing emotional distress. The intention is both to prevent the development
of mental health problems, and to support the recovery of those with existing
mental health problems. The aspiration is to widen the wellbeing offer in the
integrated care teams over time, with the addition of peer-coaches, self-management
courses and (potentially) other resources such as dementia care navigators.
Tower Hamlets Together MCP is establishing four ‘wellbeing hubs’ across the
borough to provide a single point of access to information on health, wellbeing,
social and other resources available within the local community, as well as
providing links to key services such as public health, social care, and voluntary and
community sector organisations. Once established, it is expected that these hubs will
hold detailed information on local mental health provision and will be able to direct
people to appropriate services. Similarly, professionals in mental health services will
be able to signpost their clients to the wellbeing hubs for support in addressing their
wider needs, including lifestyle services, health trainers and employment support
among a range of other services.
A related approach is ‘local area co-ordination’, currently being used by the
My Life a Full Life (Isle of Wight) PACS vanguard. Co-ordinators are recruited from
the local community and are responsible for developing detailed knowledge of the

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various assets available in an area (usually covering a population of around 12,000).
Co-ordinators work with people with mental health needs, disabled people and
older people at risk of loneliness and isolation. They help people to identify their
strengths and skills and make use of these in their local community, reinstate their
social networks and build new relationships, and explore what a ‘good life’ would
look like for them.
Supporting personal recovery
The concept of ‘recovery’ in mental health has been defined as ‘living a satisfying,
hopeful and contributing life even with the limitations caused by illness’ (Anthony
1993). Enabling personal recovery has been a focus for mental health services for
many years, and some vanguards are building on this by introducing or expanding
services that focus on support for recovery.
One increasingly common approach is the development of peer-led ‘recovery
colleges’ to share knowledge and evidence about recovery, self-care and self-
management (Burhouse et al 2015). In North East Hampshire and Farnham PACS,
the recovery college model has been expanded as part of the vanguard’s work.
Originally developed for individuals living with long-term mental health problems,
the remit of the college has extended to focus on both mental and physical health,
and there is a dedicated course exploring the links between the two. Work is
ongoing to further develop the offer, particularly to enhance the focus on physical
health, wellbeing and prevention.
Developing more effective ways of supporting recovery is also a component of the
work being done by the MERIT vanguard, with the aim of preventing relapse and
readmission wherever possible. The alliance is exploring how resources and assets
in local communities can be mapped more systematically and used to help people
in their recovery. Part of this involves thinking about the role of employers in
supporting people back into work, including through the provision of mental health
first aid training to local employers.

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Urgent care needs
In addition to improving services for people with highly complex and ongoing care
needs, many of the vanguards are redesigning urgent and emergency care services.
This is obviously a key focus in the urgent and emergency care vanguards but has
also been given attention in some MCP and PACS sites.
Many of the urgent and emergency care vanguards are expanding their psychiatric
liaison service to meet the ‘core 24’ standards, making the service available 24 hours
a day, 7 days a week (Aitken et al 2014). While this is a requirement of the Forward
View for Mental Health (Mental Health Taskforce 2016), some of the urgent and
emergency care vanguards are using this as an opportunity to expand psychiatric
liaison services further. For instance, the Leicester, Leicestershire and Rutland
System Resilience Group urgent and emergency care vanguard is incorporating
consultant psychiatrists into its mental health triage nurse service and the frail older
people’s assessment and liaison service. The liaison psychiatry service will also align
with the alcohol team based in the emergency department.
Other developments seeking to better integrate mental health into urgent care
pathways include the following.
•
• Safe Havens in North East Hampshire and Farnham were initially introduced as
a short-term pilot in 2014 but have now been expanded through the vanguard
programme. These services provide a safe space for people who are at risk of a
mental health crisis, seven days a week, in community settings. The model is
also being adopted in the Isle of Wight vanguard and elsewhere.
•
• Cambridgeshire and Peterborough urgent and emergency care vanguard has
developed a First Response Service that directs 111 callers to 24/7 support
and mental health crisis response. The service consists of: experienced
psychological wellbeing coaches who provide initial assessment via telephone; a
co-ordinator who oversees the coaches and co-ordinates calls from emergency
services; and first responders (mental health nurses or social workers) who
provide face-to-face assessment and crisis management.
•
• Many vanguard sites (and other areas of the country) are seeking to improve
the care people receive when in contact with the police. For example, in
Cambridgeshire and Peterborough urgent and emergency care vanguard,
a mental health practitioner is present in the police control room between

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8.00am and 10.00pm (weekdays) and between 1.00pm and 9.00pm (weekends)
providing advice to frontline officers.
•
• In Leicester, Leicestershire and Rutland urgent and emergency care vanguard,
a street triage service staffed by police officers, paramedics and mental health
nurses operates three days a week (Friday to Sunday). Currently, 50 per cent of
the people who are in contact with the service are taken to AE; the vanguard
aims to reduce this to 12 per cent.
•
• The MERIT vanguard is developing a co-ordinated emergency response system
across the four participating mental health trusts, with the aim of reducing
the time people who come into contact with mental health services spend
unnecessarily in AE or police cells. This involves the introduction of standard
operating procedures as well as making systems more flexible so that crisis
care is provided in a consistent and efficient way. One aspect of this is the
introduction of a new bed management system that will allow professionals
working across mental health services to better manage beds in order to reduce
inappropriate out-of-area placements.
Whole-population health
Guidance from NHS England is clear that MCPs and PACS have an important
role to play in reducing future demand on services through health promotion
activities and the prevention of ill health. However, we found few examples of MCPs
and PACS conducting work intended to improve the health of the whole local
population, particularly in relation to mental health.
Tower Hamlets Together provides one example of a vanguard site aiming to progress
towards a population health management approach involving both mental and
physical health. As part of this work, the main mental health provider involved in
the vanguard (East London Foundation Trust) has recruited a public health lead
to support the development of more integrated preventive pathways, working
alongside a public health consultant reporting to the Tower Hamlets Together
partnership. The box below provides further detail on some of the work being done
to underpin population health management in Tower Hamlets Together.
Wider work being conducted in some vanguard sites may have an impact on
population mental health and wellbeing over time. For example, in the Morecambe

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Bay PACS vanguard several initiatives are under way aiming to support local people
to take part in and lead activities that promote their health and wellbeing, such as
community-led ‘wellness days’ in Barrow-in-Furness. By reducing social isolation
and improving general health and independence, initiatives of this kind may also
have a positive effect on mental health outcomes.
Population health management in Tower Hamlets Together
Population-level data
In order to understand health inequalities and health service utilisation across the borough,
Tower Hamlets has created a linked dataset with patient-level information from acute
services, primary care, primary care prescribing, social care, mental health, community
services and continuing health care. Other areas of health and social care activity, including
public health and specialised commissioning, are to be incorporated in future. This has
enabled Tower Hamlets Together MCP to accurately assess how mental health conditions
impact on activity and costs across the system.
Initial work has focused on how activity and cost differ for people across four primary care
registers (depression, dementia, serious mental illness and learning disabilities) alongside
four long-term condition pathways (diabetes, COPD, cancer and chronic kidney disease).
This analysis is helping to shape the development of new whole-person pathways. For
example, the organisations involved are currently developing ‘test and learn’ pilots of a
consultant psychiatrist role within renal outpatients, and health psychologists to support
people with diabetes in GP practices.
Realigning incentives through new approaches to reimbursement
The linked dataset in Tower Hamlets was created to support plans for a new contractual
approach based on a capitated budget. Local providers are now beginning to use the
dataset to help understand how linked data can support clinicians to redesign pathways
and services, and to understand the quality, strategic, commercial and financial
opportunities and risks of a capitated approach to contracting.
As a first step in testing how financial risks and opportunities might be shared across the
provider partnership, the partners have been working together to deliver against a shared

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Supporting infrastructure
Vanguard sites have invested in various forms of infrastructure to support the kind
of service changes described earlier in this section. This has included redesigning
the workforce, and using technology in new ways to improve the delivery of care.
Developing new and extended roles
Many vanguard sites have explored new and extended roles as part of new models
of care, including care navigators, case managers, hybrid health and social workers,
health and social care co-ordinators, discharge co-ordinators based in acute wards,
recovery coaches (with lived experience of mental illness), and a variety of roles
provided by voluntary sector partners focused on supporting wider wellbeing. These
kinds of workforce innovations are a common feature of work on integrated care,
Population health management in Tower Hamlets Together continued
local incentive scheme in 2016/17. This scheme places £1.7 million of provider income
at risk and makes available a potential £1 million benefit to providers, dependent on the
delivery of 10 outcome goals over the course of the year. Two of these relate to mental
health: emergency admissions for people with depression, serious mental illness or
dementia; and total bed days for the same groups.
In 2016/17 there was a statistically significant 12.7 per cent reduction in occupied bed
days for people with depression, serious mental illness and dementia, while rates of
emergency admissions have remained static. The intention now is to incentivise outcomes
for emergency admissions through a new community health services alliance contract, and
discussions are under way with the clinical commissioning group (CCG) about a reward pool
against a similar set of metrics for 2017/18.
System-wide outcomes framework
Tower Hamlets partners are currently working with service users, carers, citizens and
clinicians to develop a system-wide outcomes framework, including mental health and
wellbeing outcomes, which defines the partners’ collective ambition for improving outcomes
for people who live in the borough. It is anticipated that the partners will begin to monitor
performance against the outcomes framework during 2017/18.

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although in some cases there is a need for more evidence on the impact of these new
roles on patient outcomes (Gilburt 2016a).
Many of the extended roles identified in our case study sites involved the appointment
of senior (band 7) mental health nurses into integrated care teams. Seniority was seen
as being important given the need for these professionals to work across different
services in a highly autonomous and flexible way.
Tower Hamlets Together MCP has developed a competency set for new and extended
roles to define the integrated care skills that mental health professionals need, as
well as the mental health skills that community teams need in order to do their job
safely and effectively. This includes: history-taking and mental state examinations;
engagement skills and principles around building a positive therapeutic relationship;
risk assessment and management; recovery-oriented care; and dealing with
psychiatric emergencies. Those involved are now working with Bournemouth
University to turn these competencies into a training package for GPs and practice
nurses with a focus on managing severe mental illness in primary care.
The MERIT vanguard is also reviewing the training needs and skill-mix of its staff
in order to deliver mental health services that are more consistent across a number
of sites. As part of this they are considering how staff may work more flexibly across
the four trusts involved in the alliance.
Informatics and technology
Several vanguards have sought to address issues with informatics and technology
– for example, in relation to the interoperability of IT systems. In North East
Hampshire and Farnham PACS, the Hampshire Health Record allows GPs to see a
more comprehensive picture of a patient’s history. This means they can share patient
information within the system, and staff in AE and out-of-hours services can view
GP records, past medical history, medication lists and allergies. The vanguard site
is working towards having a shared care record for all services across the vanguard
area, including mental health services.
Similarly, West Cheshire Way MCP is using a shared care record in the integrated
care teams but this is still read-only; the team do not have a shared care plan that
they can all edit dynamically.

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The acute care collaboration vanguard, MERIT, is introducing an integrated patient
record system in 2017 across the four participating mental health trusts, to ensure
that service users receive rapid support, wherever they are and regardless of which
trust’s area they come from.
In addition to shared care records, some vanguards are rethinking how care is
delivered through digital technology. For instance, MERIT is also planning to
introduce a co-ordinated bed management system across the four participating
trusts. This will enable staff to identify where beds are available using visual
electronic boards to provide ‘at a glance’ information. The aim is that patients are
less likely to be placed in a bed outside the area.
Summary
The range of developments reviewed in this section illustrates the progress that has
been made in some vanguard sites in integrating mental health into new models of
care for people with highly complex needs, ongoing long-term and/or urgent care
needs. These examples may be helpful to local system leaders when designing new
models of care. The next section focuses on delivery, as we examine some of the
practical lessons learnt across our three case study sites.
Some of the developments described are consistent with known best practice and
guidance. For example, there is an established evidence base behind models such
as ‘core 24’ liaison psychiatry. In other cases, there is a need for more evidence
about what works. For example, as discussed in the next section, it remains to be
established what best practice would look like in relation to incorporating mental
health expertise into integrated care teams. These evidence gaps highlight the
importance of adequately evaluating the mental health components of new care
models – a theme we return to in section 6.

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5 Emerging lessons for
local system leaders
There is no simple rulebook to guide successful integration of mental health within
new models of care. However, based on our research in several vanguard sites,
we have identified some practical lessons that will be relevant for local leaders
involved in the development of new models of care in other parts of the country.
As MCPs, PACS and other models are rolled out in new areas (including through
the implementation of STPs), these emerging lessons provide timely insights into
some of the key factors that need to be considered.
As with the previous section, the analysis here is based primarily on research
conducted in three case study sites (see Appendix B) but also draws on interviews
with leaders in other vanguard sites. Appendix A gives a list of useful resources for
commissioners and system leaders relating to the integration of mental health care.
Incorporating mental health into integrated care teams
The value of including mental health in integrated care teams was clear for those
interviewed in our case study sites. GPs and multidisciplinary team members
reported that they found the contribution of mental health colleagues extremely
valuable, and adding extra in-house capacity and/or developing arrangements for
closer working with other mental health teams was seen as a high priority for future
service improvement. In several sites, there was an ambition to increase the level of
mental health input over time, in recognition of the high levels of demand among
the population groups served.

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Mental health expertise was seen as adding value to the work of integrated care
teams in a number of ways, including through:
•
• supporting a more holistic assessment of people’s needs
•
• improving care for people with complex needs, including depression
or other mental health problems alongside co-morbid and multimorbid
physical conditions
•
• improving psychological aspects of care for anyone supported by the team
(see ‘Broadening the scope of mental health’ below)
•
• improving dementia management
•
• providing consultation and training to community health teams and
primary care professionals.
It remains to be seen whether the best approach is always to embed mental health
professionals within multidisciplinary teams or whether it can also be effective to
seek input as and when needed through consultation/liaison arrangements (or a
combination of the two). Professionals working in a fully embedded model argued
that it can be very helpful for mental health colleagues to be able to contribute
to all case discussions, regardless of whether a person has an identified mental
health problem. However, some mental health trusts expressed concern that their
workforce would be spread too thinly if teams were fragmented across a number of
local integrated care teams, each covering a relatively small population. They feared
that this could create challenges in terms of supervision arrangements, professional
development, and recruitment and retention, as well as loss of economies of scale.
The optimal number and professional mix of mental health staff within these teams
is not yet clear. Where mental health professionals are fully integrated, at present
this is generally limited to a relatively small number of nursing staff. In some cases,
consultant psychiatrists have been linked to these teams to provide consultation and
advice. Some integrated care team members remarked that it would also be helpful
to have access to psychologists, either in-house or through close relationships with
other teams.

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Broadening the scope of mental health
Building on these experiences, when developing new models of care it is important
to recognise that mental health expertise can add value to the care of a broad range of
people, including but not limited to those with a diagnosable mental health problem.
Many of the examples from the vanguard sites serve a wider population, and illustrate
that knowledge and skills around psychology and mental health are important
ingredients of integrated care, whatever the client group. Ensuring integrated care
teams have access to these forms of knowledge and skills allows teams to:
•
• understand the psychological aspects of care – for example, the impact of
psychological factors on engagement and capacity to self-manage
•
• provide care to people with ‘sub-threshold’ symptoms (such as distress,
fear or loneliness) that do not meet psychiatric diagnostic criteria but which
may nonetheless be highly debilitating and detrimental to physical health
•
• help people to adjust psychologically to the challenges of living with a
long-term condition (or multiple conditions)
•
• improve the management of persistent physical symptoms where there is
an interaction with psychological factors.
Focusing on prevention as well as care
Several of the vanguard sites involved in our research have attempted to use the
development of new models of care as an opportunity to strengthen the provision
of preventive interventions, such as improving the mental health and wellbeing of
people receiving support from integrated care teams and preventing further
deterioration in their condition. This has often involved working closely with
the voluntary sector.
For example, the wellbeing co-ordinator role in integrated care teams in West
Cheshire Way MCP is highly valued and is seen as having had a very positive
impact on people supported by the team. As a result, there are plans to expand the
wellbeing offer over time (see section 4). Similarly, in North East Hampshire and
Farnham PACS, the Making Connections programme (run in partnership with
Age UK) has been seen as a successful way of connecting people with non-medical

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and community services to improve their health and wellbeing, and enabling GPs
and integrated care teams to offer an additional type of support. In these examples,
voluntary sector organisations are increasingly being seen as a core part of the
delivery system rather than as an external partner.
The sites we studied had also partnered with their local authority, and had made
links with the local health and wellbeing boards. However, we did not find examples
where preventive work had made full use of local authority services such as debt
advice, employment support, fire service and housing. This is an area where future
care models could extend their scope in order to strengthen work on population
health management.
Developing the workforce
Developing mental health competencies in the general health and care workforce
should be a core objective for new models of care. Several vanguard sites have made
attempts to strengthen the competence, confidence and skills of GPs, integrated
care teams, care home staff and others in relation to mental health – although there
remains much more to be done on this front to ensure that all professionals have
the necessary skills. Building capacity in this way is important given the mismatch
between the level of mental health needs in the population and the availability of
mental health expertise. Developing the skills of non-specialists can also help to
reduce the stigma attached to mental health by making it a normal part of care.
In some vanguard sites, mental health professionals involved in new models of care
have had an explicit role in education and training. For example, in West Cheshire
Way MCP, a new older people’s consultant psychiatrist post has been created to
provide educational input into the integrated care teams and primary care. In Tower
Hamlets Together MCP, mental health nurses in the integrated community health
team have protected time to provide training to primary care as well as to community
health teams.
Inter-professional approaches can be a particularly effective way of improving skills
across the workforce. For example, the North East Urgent Care Network vanguard
has funded multi-agency simulation training involving mental health professionals,
Northumbria Police and other partners, which has been regarded as very successful.

5
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A further lesson in relation to workforce is that new models of care can be used to
create new opportunities to promote staff wellbeing. For example, in North East
Hampshire and Farnham PACS, the vanguard work has included an explicit focus
on the mental health and wellbeing of the workforce, and outcome measures include
indicators on this.
Building the right relationships
Developing a new model of care such as an MCP or PACS involves establishing
or strengthening relationships that span system boundaries. We found that the
work conducted in many vanguard sites was seen as having enabled conversations
between providers that otherwise would not have happened. For example, one
interviewee described the most innovative aspect of the work in North East
Hampshire and Farnham PACS as being the coming together of organisations that
have traditionally operated in relative isolation from one another, particularly NHS
and voluntary sector organisations.
It is important to recognise that relationship-building takes time and may require
cultural change within organisations. We heard that several factors can facilitate
this, including direct communication, regular face-to-face meetings, co-location of
integrated teams, and the alignment of strategic objectives.
Some interviewees stressed the importance of having mental health leaders ‘around
every table’ in order to consistently keep mental health on the agenda. One reported
that it was particularly helpful to have someone with recent experience of delivering
mental health services within the central programme management office responsible
for overseeing the implementation of a new model of care, to help identify and
articulate the value that mental health expertise can add to different components of
the model. There may also be value in creating strategic joint posts accountable to
all partner organisations rather than working for one organisation. For example, in
Tower Hamlets Together MCP, there is a public health post for the vanguard. This
was reported to be particularly valuable as it creates capacity to do system-wide
work across the local area.

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Co-design and public involvement
The overarching purpose of developing integrated approaches to care is to effectively
respond to the full range of a person’s needs. Engaging with service users to identify
and understand these needs and recognise the outcomes that matter to them is a
prerequisite for getting the approach right.
There were several examples of public engagement in the vanguard sites included
in our research, where the views of service users and carers were sought early in the
design process and had a direct influence on the subsequent development of the care
models. For example, co-design and service user involvement have been integral
to the development of new models of care in North East Hampshire and Farnham
PACS, particularly with regard to the Safe Havens and Recovery College.
Engagement can include co-design of specific service models, co-delivery of
services and local representation at all levels of the vanguard work – for example,
through citizen representation on working groups. Building links with the voluntary
sector and local Healthwatch was seen as another way of facilitating meaningful
public engagement.
Starting small and learning from experience
A common piece of advice for those involved in the development of new care
models is to initiate new services on a relatively small scale, and subsequently expand
them if they prove successful. This enables models to be tested and adapted if
necessary. Continuous evaluation of outcomes and user feedback can help identify
where changes may be required.
In Tower Hamlets Together MCP, a quality improvement methodology has been used
to structure this process of testing and learning. The approach taken has involved
encouraging frontline teams to identify problems when rolling out integrated care
and to offer solutions.
When scaling up or spreading models, it is important to retain experience and
learning. Some of the vanguard sites involved in our research told us they had
benefited from maintaining consistent leadership and ‘organisational memory’ –
for example, by ensuring that service managers that have been involved in the
design and running of the pilot phase are also involved in scaling up the model.

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6 What next?
The new models of care being developed in the vanguard sites have been described
by NHS England as ‘a blueprint for the future of the NHS’ (NHS England 2016d).
Given the strategic significance of these models, it is worth standing back from the
details described in the previous sections and reflecting on the overall picture. In
this section, we consider the extent to which the opportunities to develop integrated
approaches to mental health within new models of care have been realised in
practice. We also explore what needs to happen next as these models are rolled out
across the rest of England through STPs and other mechanisms.
Progress so far
National policy has been clear that one of the objectives of the new care models
programme is to dissolve the boundaries between mental health care and the wider
system. For example, guidance published by NHS England describing the emerging
care models in MCP and PACS sites indicates an expectation that mental health
should be an integral part of these models (NHS England 2016g, 2016c). However,
while this general principle may have wide support, our research found that it has
not consistently been put into practice.
The examples we provided in section 4 illustrate that in some vanguard sites there
has been a focus on mental health, and some concrete developments have been
made as a result. It is important to acknowledge and examine these developments –
many of which are ongoing processes – and to learn from them. However, it is not
always clear that the changes introduced go substantially further than innovations
seen in other parts of the country, or indeed than the expectations laid out in
national policy. For example, many of the changes being introduced in urgent
and emergency care vanguards (such as strengthening liaison psychiatry services
in acute hospitals) have been identified as requirements in the Forward View for
Mental Health as well as in NHS England’s Urgent and emergency care route map
(NHS England 2015), while other components seen in these sites (eg, street triage)
are being implemented widely across England through local Crisis Care Concordat

What next? 43
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plans. Similarly, some of the mental health components of MCPs and PACS mirror
work being conducted elsewhere – for example, the Recovery College model
described in section 4 is becoming increasingly common throughout the country.
It is also clear that mental health has been a higher priority in some vanguard
sites than others. While many of the urgent and emergency care vanguards have
included substantial mental health programmes within their work, in the acute care
collaboration vanguards there appears to be little consideration of mental health
(with the exception of the MERIT vanguard). This is a missed opportunity, as some
of the pathways being focused on in these vanguards could benefit from a mental
health component. For example, integrating mental health treatment into cancer
pathways has been found to improve mental health outcomes, reduce pain and
fatigue, and improve general functioning and quality of life (Sharpe et al 2014), and
there would be value in testing such approaches as part of new models of cancer care.
It should be noted that the three MCP and PACS vanguards we studied in greater
depth were chosen because our scoping interviews indicated that they included a
number of mental health components. As such, they do not necessarily reflect the
overall level of priority placed on mental health across the vanguard programme.
And even in these sites, it was notable that staff in integrated care teams suggested
that extra mental health capacity would be highly valuable, indicating that the
resources available may not yet fully meet the needs that exist.
Comparing the progress observed with the nine design principles developed by our
expert group (section 3), a mixed picture emerges. A notable positive finding is that
in many of the sites where we conducted research, we did find evidence that the
development of new models of care had helped to foster relationships and networks
between health care professionals working in mental health and physical health, at
both the clinical and strategic levels (principle 6). New care models are also being
used as a vehicle to provide appropriate mental health training to frontline staff – for
example, in integrated care teams and primary care (principle 9). However, there is
still some way to go before services are consistently providing a truly whole‑person
approach spanning an individual’s physical, mental, emotional and social needs.
As an illustration of this, integrated care teams were described in one MCP as
‘predominantly a physical health service’ despite the inclusion of some mental
health staff.

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Overall, we conclude that although important foundations have been built in several
local areas, the full opportunities for integrating mental health within new models
of care have not yet been realised. It should be acknowledged that the purpose of
the vanguard programme was not to introduce a comprehensive package of reforms
in all 50 sites, but rather to prototype and test different components of new care
models across the sites involved. In relation to mental health, the critical measure
of success is that taken together, the work done in the vanguard sites allows us to
test hypotheses about the potential impact of integrating mental health within new
models of care. Our concern is that the service changes implemented to date may
not be sufficient to allow for these hypotheses to be adequately tested.
Barriers to be overcome
Attempts to develop any form of integrated care can run into barriers created
by the institutional fault lines in the health and care system – non-interoperable
information systems, information governance issues, difficulties pooling budgets
across sectors, and difficulties finding shared premises for integrated teams, to name
just a few. As might be expected, our research confirmed that these generic system
barriers have been encountered in some vanguard sites.
Of greater interest here, we also found other barriers relating more specifically
to the inclusion of mental health in new models of care. Mental health leaders
involved in our research expressed the need to be physically present at all relevant
meetings to keep mental health firmly on the new care model agenda, even where
it had been identified as a strategic priority for the vanguard. In the words of one
vanguard leader, ‘people know it’s important but operationalisation is challenging’.
In this context, tokenism is an ever-present danger – the risk being that references
to mental health are included in strategic documents, but without a clear plan for
delivering these ambitions.
The expectation from policy-makers that vanguard sites will provide rapid answers
to the current pressures in the health system, and the consequent focus of new
care models on groups who use most resources in the here-and-now (often older
people with frailty), appears to have sometimes steered strategic thinking away from
addressing needs relating to mental health. Some of the leaders involved in our
research felt that because of the pressure to demonstrate in-year savings, there had
been insufficient space to develop innovative approaches to mental health care. This

What next? 45
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illustrates the difficulty of trying to achieve transformation within available
resources, even with the additional funding that vanguard status has delivered.
The situation was not helped by the financial settlement received by vanguard sites
in 2016/17 and 2017/18. In some areas, some of the mental health components
included in original vanguard plans had been scaled back or cancelled because
national funding was less than expected (it should be noted that this experience
was not limited to mental health components alone). Furthermore, we found that
the non-recurrent nature of vanguard funding was seen as a significant barrier in
some areas.
As with other parts of the health and care system, mental health services in England
are currently operating under extreme pressure as a result of ongoing financial
stringency, rising demand and workforce shortages (Gilburt 2016b, 2015). Some
mental health professionals expressed concern that in this context, an increasing
focus on integrated working (for example, embedding mental health staff in
integrated care teams or working more closely with primary care) could involve
resources being diverted away from specialist services for people with severe
mental illnesses. In the longer term, it is possible that by responding earlier and
more effectively to emerging mental health needs, integrated working could reduce
pressure on other mental health services (and indeed on wider health and care
services). However, in the interim, it is important to ensure that investment in
integrated working does not deplete much-needed resources for core mental health
provision. Further research is needed to identify the specific components that are
needed if integrated approaches to mental health are to help alleviate pressures
elsewhere in the system, and to clarify the timescales over which this can happen.
Opportunities ahead
Previous publications have discussed the potential benefits of developing more
integrated approaches to mental health at all levels of the health system, from
prevention to acute hospital care (Naylor et al 2016; Royal College of Psychiatrists 2013).
If these opportunities have not yet been realised in full, what should the next steps
be? One way to answer this question is to focus on the four levels of the MCP and
PACS care models (see section 4), which provide a description of the main areas
where it is intended they will bring about improvements. There are substantial
opportunities to make further progress at each of these levels (as described below).

What next? 46
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•
• Complex needs: Ensuring that local integrated care teams are able to make
full use of mental health expertise in supporting people with complex and
ongoing care needs, with mental health staff able to input proactively into all
case discussions and offer advice and training to the wider team.
•
• Long-term care needs: Making new forms of mental health support a central
component of enhanced models of primary care, so that primary care teams
are better equipped to address the wide range of mental health needs in
general practice (including among people presenting primarily with physical
symptoms), and also to address the physical health needs of people with
long‑term mental health problems. This will need to be done in a way that
is aligned with wider efforts to transform primary care to ensure that it is
sustainable for the future (see box, p 47).
•
• Urgent care needs: Strengthening mental health components of urgent and
emergency care pathways. Again, this should include appropriate mental health
support for people presenting with physical health symptoms as well as those
experiencing mental health crises.
•
• Whole-population health: Incorporating a focus on public mental health and
wellbeing within population health management approaches, recognising the
role of poor mental health as a major risk factor for many other conditions.
This should include work on perinatal mental health, children and young
people (where some of the greatest opportunities for prevention lie), and also
on wider services such as drug and alcohol, homelessness or housing services
and employment support.
Further evidence will be needed to guide action at each of these levels. As such, local
and national evaluations of new models of care should include an assessment of
their impact on people with mental health problems as well as on mental health and
wellbeing-related outcomes across the wider population. It will also be important
to assess how the mental health components of the new models of care have
contributed to wider health and social outcomes. The ‘learning and impact studies’
to be conducted as part of the evaluation strategy provide one potential means of
testing the mental health components of the models (Tallack 2017).
Learning from the vanguard sites should be combined with existing evidence about
good practice. Many of the service models recommended in the Forward View for

What next? 47
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Mental Health are supported by a considerable evidence base, and implementing
these tried-and-tested models should proceed in parallel with attempts to integrate
mental health into new models of care. There may also be relevant learning to draw
on from other national programmes – for example, from areas that are currently
piloting new approaches to child and adolescent mental health and secure care
services (NHS England 2014).
As new models of care are developed in other areas beyond the vanguard sites, two
things will need to be done to ensure that the opportunities relating to mental health
are not missed. First, testing the mental health components of existing vanguard
sites must be a central part of the evaluation strategy for new care models, as already
argued. Second, looking beyond the vanguard sites, local areas rolling out an MCP
or PACS model should aim to go further than the vanguards in the four areas listed
above. To support this, we would again highlight the importance of including
mental health from the initial design stages of new models of care, rather than as
an adjunct.
Mental health and enhanced models of primary care
Transforming primary care is a major priority in many parts of the country. The extreme
pressures being experienced in general practice make it clear that primary care services
are not sustainable in their current form, and that substantial changes to models of general
practice are now inevitable (Baird et al 2016). The proposals in the GP Forward View build
on the ongoing trend of GPs joining with other professionals in practice groups, federations
and a variety of other models (NHS England 2016a). As local system leaders think about
how to transform primary care, it is important that new approaches to mental health care
are integral to their plans, given the high levels of unmet or poorly met mental health care
needs among people using GP services, and the impact of this on patients and staff alike.
The 3,000 additional primary care mental health workers announced in the GP Forward View
may play a part in this, but further detail is needed on where these workers will come from
and what roles they will perform. The expansion of the physician associate workforce also
potentially creates an opportunity to deliver more integrated mental health in primary care
and elsewhere. The educational curriculum for physician associates currently includes limited
coverage of mental health, so additional training may be required for these professionals to
support integrated working.

What next? 48
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The policy intention is that most of England’s population will be covered by MCPs,
PACS or similar care models within the next few years, with STPs being seen as
the primary vehicle for rollout. Concerns have been raised that some STPs include
only limited content on mental health and are not well aligned with the national
ambitions laid out in the Forward View for Mental Health and elsewhere (Gammie
2016; Naylor 2016). It is vital that STP leaders are encouraged to make mental health
a central part of their plans, and that they are able to take heed of the emerging
lessons from vanguard sites. Data packs recently commissioned by NHS England
may help STP leaders in selecting areas to focus on, but there will need to be
additional support in terms of designing and implementing the care models that
flow from this (Gammie 2017).
In the longer term, several parts of the country are seeing MCP and PACS models
as a staging post on the way to building accountable care organisations or systems,
with NHS England and NHS Improvement providing support to a number of areas
exploring these approaches (NHS England 2017). This would involve: developing a
single capitated budget for a broad range of services (potentially including mental
and physical health care); building a single provider or partnership capable of
holding that budget; and shifting the focus of commissioners towards measuring
high-level, longer-term outcomes (Collins 2016). There are potential opportunities
in these types of reform for integrated providers to choose to invest resources in
mental health care in order to improve broad population health outcomes and to
deliver better value across the wider system (the box below provides indicative
evidence about the scope to deliver better value by doing so). It is important that
mental health providers ensure they are active partners in the development of
accountable care systems and organisations if these opportunities are to be realised.

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Can integrated approaches to mental health deliver better value?
In primary care
•
• Integration of mental health into primary care teams in Intermountain Healthcare, an
integrated health system in the United States, was associated with lower use of some
forms of acute care and reduced costs in real terms across the system (Reiss-Brennan
et al 2016).
•
• An evaluation of an integrated mental health service in GP practices for people with
persistent physical symptoms and other complex needs in City and Hackney (London)
found that over a follow-up period of 22 months, around a third of the costs of
providing the service were offset by savings from reduced service use in primary
and secondary care (Parsonage et al 2014).
In long-term conditions management
•
• In a research trial in the UK, integrating mental health support into cancer care pathways
using the collaborative care model improved mental health outcomes, reduced pain and
fatigue, and improved general functioning and quality of life (Sharpe et al 2014) and
was found to be highly cost effective (Duarte et al 2015).
•
• Introduction of the ‘three dimensions for diabetes’ (3DfD) service in south London,
which included integrated support for mental and social needs, was associated with
improved control of blood glucose levels among the people served, reduced emergency
attendances and reduced diabetes complications. In an economic evaluation, the
financial value of reduced hospital activity was found to be 35 per cent higher than
the costs of delivering the 3DfD service (Ismail and Gayle 2016).
•
• Including a psychological component in a breathlessness clinic for COPD in Hillingdon
Hospital led to fewer AE presentations and hospital bed days during the six months
after the intervention (Howard et al 2010). This translated into savings of around four
times the upfront costs of the intervention.

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Can integrated approaches to mental health deliver better value?
continued
In acute hospitals
•
• In the Greater Nottingham urgent and emergency care vanguard, strengthening the
mental health liaison team in AE in line with the ‘core 24’ service standard is reported
to have led to a 3 per cent improvement in the acute trust’s overall performance
against the four-hour wait target.
•
• An evaluation of the Rapid Assessment Interface and Discharge (RAID) service in
Birmingham found that on conservative assumptions, benefits in terms of reduced
inpatient bed use within the acute hospital exceeded the costs of the service by a
factor of more than four to one (Parsonage and Fossey 2011).

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